Bevan Court. Midland Heart Limited. Overall rating for this service. Inspection report. Ratings. Requires Improvement

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1 Midland Heart Limited Bevan Court Inspection report Montalt Road Cheylesmore Coventry West Midlands CV3 5JB Date of inspection visit: 06 June 2016 Date of publication: 14 July 2016 Tel: Website: Ratings Overall rating for this service Requires Improvement Is the service safe? Is the service effective? Is the service caring? Is the service responsive? Is the service well-led? Requires Improvement Good Good Good Requires Improvement 1 Bevan Court Inspection report 14 July 2016

2 Summary of findings Overall summary This inspection took place on 6 June 2016 and was announced. We gave the provider 48 hours' notice so people would be available to speak with us at our visit. Bevan Court provides an extra care service of personal care and support to older people within a complex of 41 apartments. Staff provide care at pre-arranged times and people have access to call bells for staff to respond whenever additional help is required. The complex is spread over three floors with a lift and stairs to each floor. People have access to communal lounges and a dining room. At the time of our visit 38 people were receiving personal care support. This was the first time the service had been inspected under our new methodology. We last inspected the service in September 2013 and found it was compliant. The service had a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. We refer to them as the manager in this report. They were being supported by two team leaders and the providers' locality manager for the area. People received varying levels of support from staff, depending on their needs. Some people only required a 'wellbeing' check or minimal assistance with personal care. Other people required assistance with taking medicines, continence care, and support with nutrition and mobility. People told us they felt safe with the staff who delivered their care. Staff were aware of the action they needed to take if they had any concerns about people's safety, or health and wellbeing. However, we found that safeguarding concerns were not consistently reported correctly to the local safeguarding team so that investigations could take place if required. The staff allocation sheets showed us there were sufficient staff to cover the scheduled calls to people. People told us they mostly received their care on time and staff stayed the allocated time to complete tasks. The provider was recruiting new staff and gaps in the staff rota were supported by agency staff. However, the provider used regular agency workers, and bank staff, to ensure people received support from staff that knew them. Staff received a detailed induction and training when they started working at Bevan Court. There were plans in place to ensure all staff completed the required training to ensure their work reflected good practice. Staff received supervision and support and told us the manager was approachable and supportive. Care plans did not always include important information about risks to people's health, but staff were able to talk confidently about how they managed risks, as they knew people well. Care plans were written in a 2 Bevan Court Inspection report 14 July 2016

3 'person-centred' way that supported staff in delivering care and assistance that met people's individual needs. However the manager acknowledged more detail about people and their current needs was required within care plans and they were addressing this. People were happy with the care they received and said staff were caring and friendly. Staff respected people's privacy and maintained people's dignity when providing care. The manager and staff understood the principles of the Mental Capacity Act (MCA) and gained people's consent before they provided personal care. All the people we spoke with clearly recognised that due to the support and care provided by staff, they were able to enjoy living relatively independently in their own homes. There were processes to monitor the quality of the service provided through feedback from people and a programme of checks and audits. However the provider had not sent us all relevant statutory notifications in order for us to monitor the quality of the service being provided. 3 Bevan Court Inspection report 14 July 2016

4 The five questions we ask about services and what we found We always ask the following five questions of services. Is the service safe? Requires Improvement The service was not consistently safe. The provider did not consistently follow correct procedures to report safeguarding concerns to the local safeguarding team. Staff told us they understood their role and responsibility to report concerns about people's emotional and physical wellbeing. Medicines were stored and administered safely but some medicine charts were not completed correctly. There were sufficient numbers of staff to support people. Staff understood the risks associated with people's care, and plans were in place to minimise risks identified although some lacked detail. Is the service effective? Good The service was effective. Staff received training and had the knowledge and skills to effectively support people. Staff understood the principles of the Mental Capacity Act (2005) and how to support people with decision making. People made choices about their food and drink and were supported to maintain a healthy diet. People received on-going support from a range of external healthcare professionals when required. Is the service caring? Good The service was caring. People were supported by staff who they considered kind and caring. People were encouraged by staff to be as independent as possible. Staff ensured they respected people's privacy and dignity. People received care and support from staff who understood their individual needs and supported them in ways they preferred. Is the service responsive? Good The service was responsive. 4 Bevan Court Inspection report 14 July 2016

5 People received a service that was based on their personal preferences. Care records contained detailed information about people's likes, dislikes and routines, however some required updating following changes in people's needs. People and their relatives were encouraged to be involved in reviews of their care. People were given opportunities to share their views about the service and the manager responded to any concerns raised. Is the service well-led? Requires Improvement The service was not consistently well-led. The provider had failed to send us statutory notifications about incidents that had occurred. People and relatives were happy with the service and felt able to speak with the management team if they needed to. Staff were supported to carry out their roles, and considered the manager to be approachable and responsive. The provider had systems to review the quality and safety of service provided, however these had not identified some of the issues we found. 5 Bevan Court Inspection report 14 July 2016

6 Bevan Court Detailed findings Background to this inspection We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act The inspection of Bevan Court took place on 6 June 2016 and was announced. We gave the provider 48 hours' notice so people would be available to speak with us at our visit. The inspection was conducted by one inspector and an expert by experience. An expert-by-experience is someone who has knowledge and experience of using, or caring for someone, who uses this type of service. We contacted commissioners about Bevan Court. Commissioners are people who work to find appropriate care and support services which are paid for by the local authority. We did not receive any information of concern. Before the inspection visit we looked at the information received from our 'Share Your Experience' web forms and notifications received from the provider. These are notifications the provider must send to us which inform of incidents that affect people's health, safety and welfare. Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make. We used this information as part of our inspection planning. We found that information provided within the PIR did not consistently reflect our inspection findings. For example the provider told us all safeguarding incidents were reported to the local authority and statutory notifications sent to ourselves. We found this was not consistently carried out. During our visit we spoke with the registered manager, two team leaders, three support workers and the provider's locality area manager. We spoke with ten people who used the service. We reviewed three people's care plans and daily records, to see how their care and support was planned and delivered. 6 Bevan Court Inspection report 14 July 2016

7 We looked at other records related to people's care and how the service operated including, medication records, staff recruitment files, the provider's quality assurance audits and records of complaints. 7 Bevan Court Inspection report 14 July 2016

8 Is the service safe? Requires Improvement Our findings People said they felt safe at Bevan Court. Comments included: "Yes, I'm safe. If not I'd speak to the carer." And, "Oh, I'm absolutely safe. I can't see any concerns I often think I'm glad I came here. If I didn't feel safe, I'd go and see the manager." Another person told us, "I'm very safe, there are enough staff. They're really good." We asked staff how they made sure people remained safe and were protected from abuse. Staff told us they had completed training in keeping people safe and understood the different types of abuse. Staff told us they were observant for signs that might mean someone was experiencing, or at risk of abuse, however, we found the management team had not informed the local safeguarding team of two incidents. We saw that the provider did not have robust enough procedures in place to identify when an accident or incident was the result of potential abuse or when a person could be at risk of potential harm. For example we saw one incident where a person had an unexplained injury. The provider could not establish if this was the result of an accident or abuse. In another incident one person had been reported missing from the home and had been located by Police. Neither incident had been reported to the local safeguarding team. We discussed our findings with the manager and locality manager who acknowledged procedures for reporting safeguarding concerns were not correctly followed. Prior to our inspection the locality manager had introduced a new audit tool for all the provider's registered managers in the area to use. This prompted them to examine incidents and accidents to ensure, that where relevant, safeguarding referrals were made to the local authority. We saw that the registered manager was now following this guidance and we had been notified of recent incidents and the local safeguarding team had been informed. We spoke with the manager and locality manager during the inspection and they informed us they would address the concerns we highlighted and remind staff of their responsibilities to keep people safe. In addition, the recording of incidents and falls would be reviewed by the management team on a weekly basis to ensure the correct procedures had been followed. They assured us risks related to people, and the management of safeguarding events, were being reviewed as a matter of priority. We asked the care staff how they would report concerns about abuse and the different types that could occur. A staff member told us. "I know to report concerns to the safeguarding team and send all the documents to them." We asked staff what actions they would take if they witnessed a person suffering abuse, they told us, "I would approach the abuser to stop them and then tell the managers. They tell social services, but if I thought they hadn't done that I would report to them myself." One of the team leaders told us safeguarding, and the different types of abuse, was discussed with people at the 'residents meetings'. Information was also contained in the communal area for people and relatives to read. We saw there was an 'easy read' poster on display in the communal areas advising people how they could report concerns. 'Easy read' formats use visual images and large print sizes to make the documents more accessible to people. 8 Bevan Court Inspection report 14 July 2016

9 We saw there were risk assessments associated with people's care, for example, people who needed assistance to move around or take their medicines, had care plans to manage or reduce those risks. Staff we spoke with were aware of risks to individuals and able to talk confidently about how they supported people. However we saw a risk assessment had not been reviewed for one person following several falls over the last six months. This person had been identified as medium risk in September 2015 and the risk assessment had not been updated to reflect they were still falling. They had previously been referred to the falls team for specialist advice to reduce the risk of further accidents and incidents occurring. However there had been no recent referrals to the person's GP to discuss if a new referral to the falls team needed to be made. We discussed this with the manager and the day after our inspection the person's GP was contacted to carry out a new assessment. Most people told us they received their care on time however one person commented, "They are not regular; they can come at any time. In the morning it can be half last 7 or later it could even be could be half past 9 or 10 o'clock." However other people commented, "They're pretty good at coming at 8 o'clock in the morning they're regular with that, it's always about 8." And, "They do come on time, and help me have a shower on Monday nights and they always come at 7 o'clock." People living at Bevan Court had call bells in their rooms and pendants they could press to call for staff. One person told us, "In my room I've got a cord to pull and they come straight away." During our visit we saw there were sufficient numbers of staff available to support people. The provider had introduced a new staff rota to ensure shifts were covered well in advance and recruitment was underway to meet the requirements of the new rota. Staff recorded their visits electronically and this showed visits were completed and on time. The manager told us the computer system would show if people were not receiving their allocated care hours. Missed visits were also recorded, however this was normally because a person may have had an appointment and so the care was not required. We asked if people felt there were enough staff to support them, they told us, "Yes, there are enough staff. They're really good. The new staff are learning, they're not complete strangers. We get agency, but we soon get to know them." Another told us, "Staff generally are alright, we get agency staff and some are alright, we seem to have regular ones more." We asked one person about the use of agency staff and they told us, "I'm very safe. Yes, there are enough staff. They're really good. Staff told us they felt staffing levels were sufficient to support people. One staff member told us, "I think we have enough staff to provide the care." The manager told us some gaps on the staff rota were filled by agency care staff and bank staff. (Bank staff are permanent members of staff, employed by the provider, who work occasional shifts to cover gaps in staff rotas.) The manager told us, to ensure people received care from staff who knew them; they would try to use regular agency staff. Staff files indicated that safe recruitment processes were followed including a DBS (Disclosure Barring Service) and reference checks. DBS checks were updated regularly. One new member of staff told us, "I had three references and a DBS check before I started and I had to wait until they were completed before starting." The Disclosure Barring Service is a national agency that keeps records of criminal convictions. The recruitment procedures ensured staff were safe to work with people who used the service. 9 Bevan Court Inspection report 14 July 2016

10 Some people managed their own medicines, but other people needed support to do this. People who were assisted to manage their prescribed medicines said they nearly always received their medicines when they should. One person told us, "Medicines, yes I get them, they remember to give them." Another told us, "Medication, they do that for me while I get ready, or I'd remind them, but I have never had to remind them." However two people told us staff supported them to take their medicines but they felt able to do this themselves and would like more involvement. We fed this back to the manager and they told us as part of the pre assessment process people were asked how much support they required taking their medicines. They told us they would speak with these two people to review their involvement in taking their medicines. There was a procedure for supporting people to take their medicines safely, and where people required assistance to do this, it was clearly recorded in their care plan. Staff had completed training to administer medicines and had their competency checked by the provider to ensure they were doing this safely. Completed medication administration records (MAR) showed people had been given their medicines as prescribed, however two that we looked at showed gaps where signatures of the staff recording the administration had not been filled in. We also saw that one person had not received their lunchtime medication as it was still in the sealed container (blister pack). We asked the manager about this and they told us the policy was to record on the back of the chart why a medicine had not been given. We did not see this had been done. They told us they aimed to check every MAR sheet over a month period and they checked controlled drugs stocks every day. These are medicines that have to be carefully monitored and recorded due to their strength. Team leaders told us they would also carry out three random spot checks of medicine charts every day. We saw on one of the provider's audits that missing signatures had been identified on some people's medicines charts. The manager acknowledged there needed to be a more robust auditing carried out of the medicines and assured us this would be done on a weekly basis. Some people were prescribed medicines 'as required' (PRN). However we did not see that each PRN medicine had an individual medicine plan written to inform staff when it should be given. Staff told us they should write on the back of the MAR's chart when and why someone received their medicine but we did not see this was being carried out. One person did not have a detailed entry in their care plan regarding a medicine used to regulate their blood clotting. The manager told us they would seek advice from the pharmacist how best to record this information in the person's care plan. During our inspection the team leader immediately acted on this and was putting together relevant information for staff to follow in the persons' care plan and attaching it to their medicine chart. 10 Bevan Court Inspection report 14 July 2016

11 Is the service effective? Good Our findings People told us staff were competent when providing their care and support. Comments from people included, "For me, the ones I have are trained." And, "Yes, they know what to do. If I fall over they can't just pick me up off the floor, they use a hoist and hoist me either onto the bed or the chair." One person who lived at Bevan Court with their partner told us staff would advise them not to carry out personal care for their partner on safety grounds, they told us, "Yes they are well trained, they always get me to rest if I start helping [person] to get out of bed. They say 'We're trained'." Staff told us they received an induction into the service that made sure they could meet people's needs when they started work. This included training and working alongside a more experienced staff member before they worked on their own. One new member of staff told us, "It's good training and helps me do my job. I shadowed another member of staff for one and a half weeks." A key part of the induction for new staff was completion of the Care Certificate which was introduced in April The Care Certificate sets the standard for the fundamental skills, knowledge, values and behaviours expected from staff within a care environment. Staff told us they had received training in those areas the provider considered essential to delivering care safely and effectively. The manager held records of the training staff had received and when 'refresher' training was required to ensure their skills remained up to date. One member of staff told us, "I have recently done my NVQ3 training and also I had dementia awareness training." They went on to tell us how useful they had found this as it gave them greater knowledge and understanding of how to support someone living with dementia. Staff told us they received regular supervision (one to one meetings) with the manager which gave them the opportunity to talk about their practice, raise any issues and ask for guidance. They told us, "We have supervision but we can also speak to the team leaders about anything." Another told us, "I get regular supervision and annual appraisals. I get updates on my performance but it's a two way approach." The manager told us, "Supervisions are not all in place but I plan that staff will have some form of contact every month." The Care Quality Commission is required by law to monitor the operation of the Mental Capacity Act 2005 (MCA) and the Deprivation of Liberty Safeguards (DoLS) and to report on what we find. The Mental Capacity Act 2005 (MCA) provides a legal framework for making particular decisions on behalf of people who may lack the mental capacity to do so for themselves. The Act requires that as far as possible people make their own decisions and are helped to do so when needed. When they lack mental capacity to take particular decisions, any made on their behalf must be in their best interests and as least restrictive as possible. DoLS makes sure people who lack capacity to make certain decisions do not have their liberty restricted, unless specific safeguards are in place. We did not see a mental capacity assessment or best interest decision recorded for one person who lacked capacity. However the manager had identified a need for an urgent best interest meeting following a recent 11 Bevan Court Inspection report 14 July 2016

12 incident and had liaised with the person's social worker to organise this. The manager told us this would be addressed immediately and we checked following the inspection that this had been done. The manager acknowledged they were not fully aware of the process to follow regarding a DoLS application for this person and during our visit the team leader contacted the local authority for guidance. An application was submitted the day after our visit. There were no other applications in place during our inspection. Staff had a good understanding of the principles of the Act and how this affected their practice. Care workers understood the importance of obtaining people's consent prior to providing care and support. A staff member told us they would always ask people for their consent prior to undertaking care tasks. They told us, "I would not force anyone to have care, if I was worried about their capacity I would speak to a senior member of staff. You never restrain anyone." Another told us, "You cannot force someone, after all how would I like to be treated? If I was concerned someone was refusing care I would involve healthcare professionals to see if maybe they had a urine infection." One care worker told us that if they had concerns about someone refusing personal care or medication they would encourage that person. They told us, "If they refused their medication I would try again and if they continued to refuse I would stop, document everything and then tell the duty officer." Some people were assisted by staff to make their breakfast and had a lunchtime meal in a communal dining room. One person told us, "They do my breakfast and give me cereal and I do have toast if I like and they sometimes stop and chat." Another person told us, "We get marvellous food. I've always got a drink by my bedside." We saw that where people required special diets they received it. One person told us, "I have my food liquidised it's still tasty food it's very nice. I chose haddock today and they'll liquidise that. I can have sponge and apple pie and they do liquidise that, I've always got a drink on the side of me in the flat." During lunchtime we saw the meals served in the dining room looked appetising, were well presented and nutritionally balanced. When visiting people in their homes, we saw they had a drink on a side table where they could easily reach it. People we spoke with confirmed they had enough to drink throughout the day. People's medical appointments were arranged by themselves, their relatives or staff. Staff checked people's health during their calls and took appropriate action when a need was identified. Staff were also able to arrange for healthcare professionals such as district nurses, opticians and chiropodists to visit people in their own homes. People told us, "The doctors and chiropodist come here." And, "Twice a week we get the district nurse coming." 12 Bevan Court Inspection report 14 July 2016

13 Is the service caring? Good Our findings People lived in their own flats so we were unable to observe care directly. People told us staff were caring and treated them with respect. Comments included, "It's wonderful, it's marvellous, the beds are changed every day, and the carers are wonderful, nothing is too much trouble for them." And, "I can't say anything wrong about the care here. I can't grumble about the staff." Interactions between staff and people in the communal areas appeared to be positive, caring and respectful. We observed there was friendly banter with staff, and good interactions between people. People seemed happy and at ease when engaging with staff. Staff recognised the individual needs of people they provided care and support to and listened to what they had to say. One staff member told us, "I love the way we interact with people, to see their smiles. If you find someone is down I like to know after speaking to them and giving care they brighten up." Staff we spoke with told us they enjoyed working at Bevan Court and thought the service provided was caring. We found they were highly motivated to provide good care and support people's needs. One staff member commented, "I enjoy the people here, we are a big family." Another told us, "I love my job the atmosphere here is just great." All the people we spoke with recognised that due to the support and care provided by staff, they were able to enjoy living relatively independently in their own homes. One person told us, "I'm independent as I try to be, but if I ask for anything, they'll do it." Another told us, "Yes, I think they let me be independent. They know there are a lot of things I like to do myself." Staff confirmed they promoted people's independence, with one staff member telling us, "I like to care and give support to people but I also encourage their independence." People in receipt of personal care told us they were able to express their views and guide staff as to how they wanted their care to be carried out. For example, one person told us, "We do get respect and privacy and I can say how I like things done; they do know how I like things." Another person told us, "We've got quite a lot of young carers and they come in every morning, and if I want them to help me wash and dress, they do." However one person commented to us that they did not feel able to have a choice about receiving personal care from a male care worker. They told us, "Lately there has been a man coming to help and I don't like that. I'm going to do something about it. I don't know him and I don't like it. I was a bit upset this morning. I just let him help me, but felt embarrassed." We discussed this with the manager who told us they would address this immediately with the person and that people were given choice regarding the gender of their care worker. People confirmed staff respected their homes and knocked on the door and waited for a response before 13 Bevan Court Inspection report 14 July 2016

14 entering. It was clearly stated in people's care plans how they wished staff to enter their flat, for example by ringing the bell or knocking first before requesting permission to enter. We saw staff respected this and all gained consent before going into people's flats. We spoke with the manager to see if people would be willing to speak with us in their flats and they told us they would discuss this with people to make sure they were happy for us to visit them. We asked people if they felt staff were respectful and one person commented, "Respect and dignity, definitely Yes they're very good like that." Another told us, "They respect us, even the new staff." However one person told us, "They move me, they just do it, they don't ask; I'd like that if they asked." We fed this back to the manager who told us they would address these concerns with the person immediately. We asked staff how they observed people's privacy and dignity whist giving personal care, they told us, "I ring their bell and say 'hello' so they know I am coming in. I explain why I am there and what I am going to do." And, "I draw the curtains so no-one can see in and I ask their permission before doing anything." Friends and family were welcomed into Bevan Court at any time and a guest room was available for visitors who wished to stay overnight. One person told us, "My daughter is as friendly with them as I am." One member of staff told us, "I saw one relative and they didn't look well and I went to see if they were alright. Our support goes beyond the [people who use the service]." 14 Bevan Court Inspection report 14 July 2016

15 Is the service responsive? Good Our findings All the people we spoke with were able to identify someone who they would talk to should they wish to make a comment or complaint. They told us, "I can have a chat with anyone they do sort out my problems." Another told us, "Any concerns I wouldn't be afraid to share with staff, I'm known for it." One person we spoke with commented, "If I had a complaint I'd soon tell them, but I haven't had any. I've been alright." We saw the provider's complaints procedure was on display on the notice board near the dining room and the manager told us the complaints procedure would also be produced in an 'easy read' format that would be issued to all the people living at Bevan Court. Information in the complaints record showed that the service had received a small number of complaints in the past year. These had been handled in line with the provider's complaints policy and from the information provided we could see had been resolved to people's satisfaction. The manager told us they reviewed complaints to identify trends or themes and none had been identified. People were also reminded how they could make a complaint at the group meeting involving people who use the service and were actively encouraged to report any concerns they had. On the notice board there was information called, "You say, We say." This showed where people had expressed concerns or requested more information. We saw people had requested a new television for the lounge and this had been purchased. People we spoke with told us staff were responsive to their needs. One person we spoke with told us, "I do call somebody to tell them I'm not feeling 100% and they say 'you have to stop in your flat' and they bring all my lunch and meals to me." One member of staff told us on some occasions people required more support than their allocated hours, they commented, "We may request extra hours if they are needed but we will give the support until the person is reassessed." This meant that people had their additional needs met by the service until their care package had been increased. One person told us they would like more aids to assist them moving and that their bed was uncomfortable. We raised this with the manager at the time and they told us this had not been fed back to them and they would speak with the person following our visit. We looked at the care files of three people who used the service. These contained information that enabled staff to meet people's needs in a way they preferred. However, care plans were not consistently detailed and some had not been updated when there had been changes in people's condition. For example, one person's care plan had not been reassessed following an increase in falls. The manager acknowledged the care plans were in need of reviewing and this had already been identified and an action plan put in place to ensure this was done. Staff however were knowledgeable about the people they supported and their needs. The team leader told us, "We have review sheets and we sit and discuss peoples' care needs and any 15 Bevan Court Inspection report 14 July 2016

16 concerns, we will also ask the family where relevant." We asked people if they were involved in the planning of their care. They told us, "I didn't have review plans as such, but we have meetings once a month or every six weeks and the managers there with another member of staff and me." Another commented, "I think there is a care plan but I don't know much of what's written in it. I don't know how often they review, but once or twice they've been in and someone next to the manager has gone through a plan. It's much longer than every three months, probably every year." Staff told us they had enough time to read and update care records. Staff also received a handover of information between each shift and a daily schedule of calls, which updated them with people's care needs and any changes since they were last on shift. The team leader told us that to ensure all staff knew how to support people living at Bevan Court; they did not always allocate the same staff to people. They told us, "I want all the staff to know everyone." They went on to say this was important as it allowed staff to have good knowledge of all the people living at the service. They also told us any new incident involving a person such as a change in their condition was recorded on an impact sheet which was given to staff at each shift handover for them to read. This meant staff were kept up to date with any changes and requirements of people such as a change in medication or if a person had fallen. We asked staff how they gained their knowledge of the care people required. They responded, "When we come on duty the team leader will ask when I was last on duty and then they will let me know of any changes, for example if someone has been to hospital." They went on to say, "Care plans are updated with any changes, if we notice something we tell the team leaders and they change them. We get time to read the care plans. I think there is excellent team communication here." Some people's care plans included personal information relating to their background as well as a guide outlining their likes, dislikes, hobbies, interests and other information that was important to them. The manager told us they were supporting some people to engage in day centres and one person would be attending a gardening club weekly for a period of time to provide them with more stimulation. During our visit we saw people talking in the lounge and reading and some were doing jigsaw puzzles in the communal areas. At lunch time there was appropriate music playing in the background form the 1940's and 1950's. The ambience was cheerful and people engaged with staff and each other. 16 Bevan Court Inspection report 14 July 2016

17 Is the service well-led? Requires Improvement Our findings The manager told us they understood their responsibilities and requirements of their registration. However we found they had not submitted the relevant statutory notifications to us in relation to incidents that had occurred at Bevan Court so that we were able to monitor the service people received. We spoke to the manager and locality manager about this and they acknowledged that there had been oversights in notifying us about incidents. This had already been addressed by the provider prior to our visit and we had received recent notifications from the service. Following our inspection we again spoke to the locality manager and they sent us a copy of an updated audit form that highlighted what notifications the provider was required to inform us of. This meant the manager would ensure that the relevant notifications had been sent to us. Everyone at our visit spoke positively of the manager and felt the service was well led. They told us, "I would recommend it, I do like it. The staff in the office are quite nice." And, "I think it's well-managed, the manager's very good, and she's been here for about two years." Staff told us they felt well supported by the management team and could approach them to discuss any concerns they may have. Comments made were, "They are so understanding and approachable, if you have a problem you can be assured it is sorted." And, "[Manager] is supportive to us all, we get on really well." The team leaders told us they would also act as a 'responsible person' on duty and their role would be to make appropriate healthcare referrals for people if they required them and to answer queries from staff. This meant the manager had more time to focus on other managerial and administrative tasks they needed to carry out. We asked the manager if they felt well supported by the provider and locality manager and they told us, "Yes, [locality manager] is really good, she is very supportive." They went on to tell us there were regular manager meetings where information could be shared about changes that had been made, and to share examples of good practice within the local provider services. We found there was a strong team spirit at Bevan Court and all the staff we spoke to commented on this. We observed they constantly checked on each other to see if support was required and one staff member commented after a difficult time in their personal life, that without the support of the manager, and other staff, they would not have felt confident to return to work. Staff said they had a good understanding of their role. They told us, and we observed that they enjoyed their work and valued the service they provided. They told us they were happy and motivated to provide high quality care. Staff explained they had opportunities to put forward their suggestions and be involved in the running of the service. A variety of staff meetings were held regularly and staff told us these were useful. There was a 24 hour on call rota for staff to speak with a senior member of staff outside office hours. 17 Bevan Court Inspection report 14 July 2016

18 We saw the minutes of a recent staff meeting held in May Items discussed were a reminder to staff to ensure they read impact statements about people and new staff were also welcomed and introduced. The manager told us team meetings had not been held as regularly as they would like due to the introduction of the new staff rota. This had meant there were vacancies on some shifts and the staff had been covering these. They told us, "The people living here have to come first." They went on to say as new staff were recruited this would allow more time for meetings. Service satisfaction surveys were distributed to people who lived at Bevan Court in order to obtain their feedback. People were encouraged to put forward their suggestions and views about the service they received. However we saw on the notice board that although the responses were positive there were only seven replies returned. We asked the manager about the low response rate and they told us they were keen to gain more feedback from people. They told us, "I want people's opinions; I want to hear their voice." New questionnaires were due to be sent out following our inspection and the manager told us they would be asking staff to encourage people to complete them and provide their feedback. A range of audits were undertaken to check the quality and safety of service people received. This included checks on the management of medicines, care records, personal care delivery and staff training. The manager told us they carried out random 'spot checks' (checks on staff carrying out duties) and this included at weekends. Any areas of concern were addressed with staff through supervision sessions and team meetings. The manager acknowledged that audits had not identified the issues we found regarding reporting and handling of safeguarding incidents and statutory notifications. We did see that the provider audit carried out in May 2016 had identified that medicine audits needed to be more robust and care plans needed to be reviewed and updated by the manager. This was already in progress. 18 Bevan Court Inspection report 14 July 2016